Characterization and outcome of uveitis in 350 patients with spondyloarthropathies

Uveitis in psoriatic arthritis: study of 406 patients in a single university center and literature review

BACKGROUND/PURPOSE

The manifestations of uveitis are well established in axial spondyloarthritis (ax-SpA), but not in psoriatic arthritis (PsA). We aimed to assess, in a large unselected series of PsA: (A) the frequency and clinical features of uveitis; (B) its association with PsA activity, the impact of disease and functional disability, and (C) its relationship with the biological treatment. In addition, a literature review was performed.

METHODS

Retrospective longitudinal study of PsA patients from a single referral hospital. PsA was classified according to the CASPAR criteria, and uveitis was diagnosed by experienced ophthalmologists.

RESULTS

We studied 406 patients with PsA (46.3±12.3 years). Uveitis was observed in 20 (4.9%). Uveitis was acute in all cases, anterior (80%), unilateral (80%) and recurrent (50%). Patients with uveitis had a higher prevalence of HLA-B27 (45% vs 7.5%, p<0.0001), sacroiliitis on MRI (25% vs 8.3% p=0.027), ocular surface pathology (10% vs 0.8%, p=0.021), and median PsA impact of Disease Score (5.9 (2.1-6.8) vs 1.25 (0.0-3.0), p=0.001) and Bath Ankylosing Spondylitis Functional Index (4 (1.6-5) vs 1.0 (0.0-3.5), p=0.01) than patients without uveitis.The exposure adjusted incidence rate (episodes/100 patients-year) of uveitis before versus after biological treatment decreased with anti-TNFα monoclonal antibodies (56.3 vs 9.4) and increased with etanercept (ETN) (6.03 vs 24.2) and secukinumab (SECU) (0 vs 50) (including only one patient treated in the last two cases).

CONCLUSION

The prevalence of uveitis in patients with PsA was about 5%. The pattern was similar to that observed in ax-SpA. Uveitis was associated with a worse quality of life and greater functional disability. The uveitis exposure adjusted incidence rate decreased with anti-TNFα monoclonal antibodies and increased with ETN and SECU.

Epidemiology and clinical characteristics of psoriatic arthritis-related uveitis in Madrid, Spain

PURPOSE

To describe the epidemiology and clinical characteristics of psoriatic arthritis (PsA) related uveitis in Madrid, Spain.

METHODS

A case series nested in a retrospective single-center cohort of 494 patients with PsA was performed. Patients older than 18 years old whit a clinical diagnosis PsA-related uveitis who attended the Ramon y Cajal University Hospital in Madrid, Spain, between 1st January 2017 and 31st December 2019 were included in the study. Epidemiological and clinical data were retrieved from the electronic medical records.

RESULTS

Thirteen cases of psoriatic arthritis-related uveitis (6 men and 7 women) were included. PsA-related uveitis showed an incidence of 0.05 cases per 100,000 persons/year (CI95 0.00-0.35), and a prevalence of 2.19 cases per 100,000 persons (CI95 1.24-3.79). The prevalence of active uveitis in the cohort of PsA patients was 2.6%. The first episode of uveitis (mean age of 48.15 ± 15.41 years) was anterior and unilateral in 92.31% of the cases. Most of the patients had a recurrent course (69.2%) with 0.92 flare-ups per patient/year (CI95 0.85-0.96). The uveitis preceded the diagnosis of psoriatic arthritis in 62.5% of the patients. In patients with PsA-related uveitis, HLA-B27 was present in 23.1%, HLA-Cw6 in 7.7%.

CONCLUSIONS

Uveitis is a PsA manifestation that affects roughly 1 in 37 PsA patients, and that may precede the articular symptoms. It generally presents as a unilateral acute anterior uveitis and has a recurrent course. The most frequent observed complications are elevated intraocular pressure and cataracts.

Ankylosing Spondylitis

The seronegative spondyloarthropathies are a group of autoimmune inflammatory diseases lacking rheumatoid factor or antinuclear antibody in their serum. They include ankylosing spondylitis (AS), reactive arthritis, psoriatic arthritis, spondylitis associated with Crohn's disease and ulcerative colitis, and undifferentiated spondyloarthropathies. Inflammation mostly affects the axial joints, entheses, and extra-articular structures such as uveal tract, gastrointestinal tract, mucocutaneous tissue, and heart. Uveitis is the most common extra-articular manifestation. Spondyloarthropathies, especially AS, have a strong association with the presence of Human Leukocyte Antigen (HLA)-B27 gene. AS happens earlier in HLA-B27 patients and men are more prone to the disease. Uveitis, typically unilateral non-granulomatous acute anterior uveitis, occurs in up to 50% of the patients with AS. HLA-B27 positivity correlates with more frequent flare-ups. Conjunctivitis and scleritis are rare ocular manifestations of AS. To establish the diagnosis of AS, at least one clinical and one radiologic parameter are required for definitive diagnosis. Magnetic resonance imaging (MRI) or bone scan can help early detection of the axial skeleton inflammation. The course of eye and joint involvement are not correlated. Short-term treatment with topical corticosteroids and cycloplegic agents control the uveitis attack. In resistant cases, local or systemic therapy with corticosteroids are recommended. NSAIDs, disease-modifying anti-rheumatic drugs (DMARDs), methotrexate, azathioprine, anti-IL-17A monoclonal antibodies, and TNF-α antagonists are effective treatments for ocular and systemic manifestations of AS. If not treated adequately, uveitis may become recalcitrant and extend posteriorly. Functional impairment due to joint destruction can also occur as a result of under-treatment.

Prevalence of HLA-B*27 subtypes in the Tamil population of India with Ankylosing spondylitis and its correlation with clinical features

INTRODUCTION

HLA-B*27 is strongly associated with Ankylosing spondylitis (AS). Its subtypes show considerable geographic and ethnic difference. The main aim of this study was to assess the frequency of subtypes of HLA-B*27 in the Indian Tamil AS patients.

METHODS AND MATERIALS

Adult AS patients positive for HLA-B*27 were considered for the study. The high-resolution typing to define HLA-B*27 subtypes were done using Invitrogen B kits from One Lambda (SeCore® Sequencing Kits, Thermo Fisher, United States).

RESULTS AND CONCLUSION

Prevalence of subtypes identified were HLA-B*27:04 (52.2%), HLA-B*27:05 (41.6%), HLA-B*27:07 (3.5%) and HLA-B*27:02 (2.7%). All subtypes showed disease predisposition for males. The most common extra articular manifestation seen was enthesitis in HLA-B*27:04 and HLA-B*27:05. Uveitis was mainly associated with HLA-B*27:05 and dactylitis with HLA-B*27:04. A significant peripheral joints involvement for female and axial joint involvement for males was seen in HLA-B*27:04. Our study establishes the prevalence of HLA-B*27 subtypes and the associated clinical phenotypes among the Indian Tamil population. Considering the variability of presentation, organ involvement, and disease course in different subtypes and across ethnicities it is critical to define these associations in the ethnic populations we treat for their appropriate care considering the significant negative health and socioeconomic effects of AS.

Comparison of Clinical Features in HLA-B27 Positive and Negative Patients With Axial Spondyloarthritis: Results From a Cohort of 4,131 Patients

Objective: The aim of our study was to assess the influence of the HLA-B27 status on axial spondyloarthritis (axSpA) in the largest cohort in China.

Methods: An observational, cross-sectional, and analytic study of axSpA patients from the China axSpA database was performed. Demographic and clinical data were compared in terms of the HLA-B27 status. Univariate and multivariate analyses were performed to identify variables related to HLA-B27 presence.

Results: We enrolled 4,131 patients in this study; of those, 36,95 (89.4%) were HLA-B27 positive. In the multivariate analysis, male gender (p < 0.001), younger age (p < 0.001), a disease duration of more than 3 years (p < 0.001), a family history of SpA (p < 0.001), uveitis (p < 0.001), ASDAS-CRP (p < 0.001), and biologic treatment (p < 0.001) were the main variables that were independently related to HLA-B27 presence, whereas a diagnosis delay time >36 months (p < 0.001) and psoriasis (p < 0.001) were independently related to HLA-B27 absence.

Conclusion: In Chinese axial SpA patients, presence of HLA-B27 is associated with the male sex, younger age, longer disease duration, greater family aggregation, and higher frequency of uveitis; absence of HLA-B27 is associated with longer diagnosis delay time and higher frequency of psoriasis.

The relationship of ischemia-modified albumin levels to disease activity scores and HLA-B27 in patients with ankylosing spondylitis

OBJECTIVE:

Recent studies have implicated increased oxidative stress in the pathogenesis of Ankylosing spondylitis (AS). Ischemia-modified albumin (IMA), an altered form of albumin, increases oxidative stress. This study aimed to investigate the relationship between IMA levels and other indicators of disease severity in AS.

METHODS:

This study included 63 AS patients and 48 healthy controls. Patients were examined for serum lipid profile, C-reactive protein (CRP), complete blood count, Bath Ankylosing Spondylitis Disease Activity Index, human leukocyte antigen (HLA) B27, and treatment regimen. They were categorized based on disease activity, HLA-B27 status, and the drug treatment and compared for IMA levels.

RESULTS:

The patients had significantly higher IMA levels than controls (p=0.020); among patients, the levels were higher in those with active disease (p=0.001) and positively correlated with the CRP levels. No significant difference was found between the IMA levels of the patients with different HLA-B27 status or treatment method.

CONCLUSION:

The IMA levels were higher in patients than controls and further increased in patients with active AS. IMA was associated with disease activity and can be used as an inflammatory marker in AS. More comprehensive future studies with a larger sample size may help understand the relationship in greater detail.

Optical coherence tomography angiography findings in axial spondylarthritis

The aim of this study is to evaluate the density of retinal vascular structures and their relationship with disease duration and activity in patients with axial spondylarthritis (axSpA) using optical coherence tomography angiography (OCT-A). In this case-control study, 56 eyes of 29 axSpA patients and 61 eyes of 31 healthy controls (HCs) were evaluated using OCT-A. The capillary plexus density (CPD) of vessels in the parafovea and perifovea regions was evaluated from the superficial capillary plexus (SCP) and deep capillary plexus (DPC) flow areas. The CPD of vessels in the fundus was evaluated from the radial peripapillary capillary (RPC) flow area. Foveal avascular zone (FAZ) size was measured. In axSpA patients and HCs, the mean CPD (%) in the whole retina was 50.75 ± 2.59 and 52.43 ± 2.10 (p < 0.001) in SCP, 54.00 ± 5.83 and 58.37 ± 4.36 (p < 0.001) in DCP, and 50.13 ± 2.32 and 50.13 ± 2.26 (p = 0.984) in RPC flow areas, respectively, and the mean FAZ (mm) was 0.275 ± 0.10 and 0.294 ± 0.07 (p = 0.281), respectively. A significant negative correlation was detected between the CPD and disease duration in the parafovea (ρ: - 0.306, p = 0.022), parafovea superior-hemi (ρ = - 0299, p = 0.025), parafovea inferior-hemi (ρ = - 0.270, p = 0.044), parafovea temporal (ρ = - 0.349, p = 0.008) and parafovea nasal regions (ρ = - 0.356, p = 0.007) in the DCP flow area. CPD was found to be lower in the macula, while similar in the fundus region in axSpA patients compared to HCs. The decrease in CPD was correlated with disease duration, but not with disease activity in axSpA. Small vessel structures may be affected in axSpA. OCT-A may be used to detect subclinical vasculitis in axSpA patients.

Potential predictors for frequent relapse in human leukocyte antigen-B27-associated uveitis

PURPOSE

To identify potential predictors for frequent relapse in a cohort of patients with human leukocyte antigen (HLA)-B27-associated uveitis in a tertiary referral center at the initial visit.

METHODS

This retrospective cohort study comprised 130 patients diagnosed with HLA-B27-associated uveitis. Subjects were divided into two groups according to the frequency of uveitis attacks (number/year): frequent relapse (FR) (who relapsed more than twice a year, 38) and infrequent relapse (IR) group (who relapsed twice or less than twice a year, 92).

RESULTS

The FR group presented more often with hypopyon or posterior synechiae at the initial presentation. Interestingly, posterior segment involvements including vitritis, vasculitis, or cystoid macular edema were not significantly different between the groups. In terms of laboratory findings, the erythrocyte sedimentation rate (ESR) was higher in the FR group. Multivariate Cox hazards analysis showed male sex, the presence of hypopyon, and ESR to be potential predictive factors for frequent relapse.

CONCLUSION

We found that male sex, hypopyon at presentation, and high ESR are potential predictors for frequent relapse in HLA-B27-associated uveitis. Identifying patients at higher risk of relapse could provide important information for patients, allowing patients to understand their condition and increase their acceptance of strict management.

HLA-B27 testing: A journey from flow cytometry to molecular subtyping

BACKGROUND

Determination of HLA-B27 status plays an important role as adjuvant in suspected cases for diagnosis of Ankylosing Spondilytis (AS). Objectives of this study were to evaluate (i) flow cytometry method in comparison with DNA microarray for HLA-B27 typing and (ii) EUROArray HLA-B27 Direct assay for HLA-B27 allele detection along with discrimination of AS/non-AS subtypes in Indian population.

METHODS

A total of 7543 patients with a presumptive clinical diagnosis of AS were referred for screening of HLA-B27. All samples were initially tested by flow cytometry, and based on its findings, 1560 samples were analyzed for the presence of HLA-B27 allele by microarray technology. A subset of samples (n = 200) were further tested by DNA sequencing for identification of HLA-B27 subtypes.

RESULTS

Screening of HLA-B27 by flow cytometry reported 1551 positive (20.56%) and 5556 negative (73.65%) cases. Remaining 436 (5.78%) samples were identified within equivocal zone. Of cases (n = 1560) analyzed by microarray method, 1333 (85.44%) and 227 (14.55%) were detected microarray positive and negative, respectively. DNA sequencing identified HLA-B*27:07 as the predominant subtype among cases showing ex2 positivity by microarray method. Of 200 cases, 20 cases (14 of HLA-B*07 and 6 of HLA-B*37) of HLA-B27 cross-reactive subtypes were also identified.

CONCLUSION

We recommend DNA typing as a complementary tool along with flow cytometry to accomplish successful HLA-B27 phenotype determination. This is the first study among Indian population to evaluate efficacy of EUROArray to detect B27 allele and its potential to indicate the presence of nondisease-associated alleles in Indian population.

Uveitis and Juvenile Psoriatic Arthritis or Psoriasis

PURPOSE

To describe the phenotype of the uveitis that accompanies juvenile psoriatic arthritis or psoriasis.

DESIGN

Observational case series.

METHODS

Setting: Two university-based referral clinics: 1 in England, 1 in the United States.

STUDY POPULATION

Five children with uveitis and psoriatic arthritis and 1 with uveitis and psoriasis Observational Procedure: Retrospective chart review.

MAIN OUTCOME MEASURES

Demographics of subjects such as age and sex; description of ocular and joint disease; surgical and other complications; medical treatment.

RESULTS

Five of the 6 children in this series had the onset of disease at or before age 6 (P = .0008 compared to expected age of onset for psoriatic arthritis in childhood). All children in this series had an inadequate response to topical corticosteroids. Most of the children were treated with systemic corticosteroids for many months, yet all of them went on to require methotrexate. Therapy with systemic methotrexate did not suffice, as all the patients also required some form of biologic therapy. Five of 6 had surgeries such as vitrectomy, cataract extraction, or a procedure for glaucoma control.

CONCLUSIONS

The observations suggest that the uveitis that accompanies juvenile psoriatic arthritis might be a distinct disease that is particularly severe when its onset affects children aged 6 years or younger.

Anti-TNFα Treatment for HLA-B27-Positive Ankylosing Spondylitis-Related Uveitis

PURPOSE

To assess the long-term efficacy of the most widely used anti-tumor necrosis factor alpha (TNFα) agents for treatment of HLA-B27-positive ankylosing spondylitis (AS)-related uveitis.

DESIGN

Retrospective cohort study.

METHODS

The medical records of 143 patients with HLA-B27-positive AS who visited Seoul St. Mary's Hospital and were taking an anti-TNFα agent for at least 1 year were studied. Subjects were divided into 3 groups according to anti-TNFα treatment: Group 1 (infliximab, 66), Group 2 (adalimumab, 45), and Group 3 (etanercept, 32).

RESULTS

Mean age was 41.0 ± 13.0 years, and 97 patients (67.8%) were male. Mean follow-up period was 70.6 ± 37.9 months. In cases of active ocular inflammation at the onset of anti-TNFα treatment, patients showed improved activity of uveitis after 24.0 ± 15.0 days (Group 1), 17.9 ± 6.0 days (Group 2), and 25.9 ± 18.0 days (Group 3). After the anti-TNFα treatment, 71 of 94 patients (32 [76.2%] in Group 1, 26 [78.8%] in Group 2, and 13 [68.4%] in Group 3) remained without uveitis relapse. A reduction in the number of systemic medications was achieved in 129 patients (90.2%). Twenty-eight cases of minor side effects were observed, and 4 cases were tuberculosis leading to discontinuation of anti-TNFα treatment.

CONCLUSIONS

Infliximab, adalimumab, and etanercept were effective for treating and reducing the number of uveitis relapses in HLA-B27-positive AS. However, the risk of serious infections was noted, so ophthalmologists should consider the possibility that prolonged use of biologic agents may result in systemic side effects.

Golimumab in refractory uveitis related to spondyloarthritis. Multicenter study of 15 patients

OBJECTIVE

To assess the efficacy of golimumab (GLM) in refractory uveitis associated to spondyloarthritis (SpA).

METHODS

Multicenter study of SpA-related uveitis refractory to at least 1 immunosuppressive drug. The main outcome variables were degree of anterior and posterior chamber inflammation, visual acuity, and macular thickness.

RESULTS

A total of 15 patients (13 men/2 women; 18 affected eyes; mean age 39 ± 6 years) were evaluated. The underlying SpA subtypes were ankylosing spondylitis (n = 8), psoriatic arthritis (n = 6) and non-radiographic axial SpA (n = 1). The ocular involvement patterns were recurrent anterior uveitis in 8 patients and chronic anterior uveitis in 7. Before GLM they have received methotrexate (n = 13), sulfasalazine (n = 6), pulses of methylprednisolone (n = 4), azathioprine (n = 3), leflunomide (n = 2), and cyclosporine (n = 1). Overall, 10 of them had also been treated with TNF-α blockers; etanercept (n = 7), adalimumab (n = 7), infliximab (n = 6), and certolizumab (n = 1). GLM was given at the standard dose (50mg/sc/monthly) as monotherapy (n = 7) or in combination with conventional immunosuppressive drugs (n = 8), mainly methotrexate. Most patients had rapid and progressive improvement of intraocular inflammation parameters. The median number of cells in the anterior chamber at 2 years [0 (0-0)] was significantly reduced compared to baseline findings [1 (0-3); p = 0.04]. The mean best corrected visual acuity value also improved (0.84 ± 0.3 at 2 years versus 0.62 ± 0.3 at baseline; p = 0.03). Only minor side effects were observed after a mean follow-up of 23 ± 7 months.

CONCLUSIONS

Our results indicate that GLM may be a useful therapeutic option in refractory SpA-related uveitis.

Uveitis in spondyloarthritis including psoriatic arthritis, ankylosing spondylitis, and inflammatory bowel disease

Uveitis is a common complication of spondyloarthritis. The "phenotype" of the uveitis characteristic of ankylosing spondylitis (sudden onset, anterior, unilateral, recurrent, more often male) may differ from the phenotype often seen with either psoriatic arthritis or inflammatory bowel disease (insidious onset, anterior and intermediate, bilateral, chronic, and/or more often female). The frequency of uveitis is also much greater in association with ankylosing spondylitis than with either inflammatory bowel disease or psoriasis. Uveitis may affect the choice of therapy and can rarely be a complication of therapy. Uveitis and arthritis also co-exist in several animal models.

Incidence of Toxoplasma retinochoroiditis in patients with ankylosing spondylitis after using TNF-α blockers

TNF-α blockers are associated with reactivation of latent granulomatous infections and almost 6% of the world population has some chorioretinitis (CR) caused by Toxoplasma gondii. Thus, the blockade of TNF-α could reactivate a latent toxoplasmosis infection (LTxI). This study was conducted to evaluate the prevalence and incidence of chronic and active CR related to T. gondii in patients with ankylosing spondylitis (AS). A total of 74 eyes from 37 active AS outpatients starting TNFα blockers were compared with 35 AS patients, matched to age and sex, under conventional therapy in a prospective and controlled trial. All patients underwent serological tests for T. gondii, as well as periodic ophthalmologic examination during 12months. Active CR was defined if a white, focal retinochoroidal lesion with overlying vitreous inflammation had been found. Retinochoroidal lesions with sharp edges, hyperpigmented borders and atrophic center were defined as CR scars. At baseline, no patient had active CR. From the 144 eyes examined, almost 6% had CR scars and only 2.1% had a typical toxoplasmic CR scar and all of them were negative for HLA-B27. During 12months of follow-up, no recurrence or new CR were observed. AS patients using TNF-α blockers do not have a higher risk of acute or chronic CR caused by T. gondii.

Ocular findings in patients with psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease affecting skin, nails, and joints. Although there are not many reports in the literature, ocular findings occur in approximately 10% of patients, in mostly those who have psoriatic arthritis. In this study, we aimed to evaluate eye involvement in psoriasis patients.

METHODS

This study was performed on a total of 100 psoriasis patients and a group of 100 healthy individuals. History was taken from all study and control subjects, and dermatological, systemic, and ophthalmological examinations were performed and Schirmer and BUT values were measured. Constant variables were compared using the t-test, and categorical variables were compared using chi-square test. Relationship between ocular findings and sex, age, duration of psoriasis, PASI score, presence of psoriatic plaques on the eyelid, nail involvement, and psoriatic arthritis was evaluated using logistic regression analysis. Statistical analyses were performed individually for both right and left eyes.

RESULTS

The number of ocular findings in both eyes in the patient group was found to be statistically higher than that in the control group. Schirmer and BUT values were statistically lower in the patient group than those in the control group.

CONCLUSIONS

Although results of our study support the necessity of routine ophthalmological examination of psoriasis patients for early diagnosis and treatment, we believe that further studies are required on the etiopathogenesis of ocular involvement in psoriasis patients.

Frequency of iridocyclitis in patients with early psoriatic arthritis: a prospective, follow up study

OBJECTIVE

The occurrence of iridocyclitis (IC) in early psoriatic arthritis (PsA) has been rarely assessed. The primary end-point of this study was to evaluate the frequency of IC at onset in patients with early PsA.

METHODS

We evaluated the frequency of IC in a clinical series of consecutive, new outpatients with early PsA observed between January 2000 and December 2009. All patients met the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria for PsA and had a disease duration ≤12 months. The following clinical patterns were considered: peripheral PsA (oligoarthritis ≤4 and polyarthritis ≥5 involved joints), axial PsA and mixed. IC diagnosis was made by the ophthalmologist. Follow-up visits were scheduled at baseline and every 4 months with interval shortening in the case of urgent clinical problems.

RESULTS

Two hundred and forty-two patients, 137 (57%) women and 105 (43%) men (mean age 50.33 ± 11.7 years; mean symptom duration 9.38 ± 3.1 months) were studied. One hundred and thirty-two (51%) patients had peripheral PsA, 41 (17%) axial and 69 (28%) mixed. Twenty-six episodes of IC were recorded at diagnosis in 22 (9%) patients, 17 (77.3%) female and five (22.7%) male; 11 (50%) patients had peripheral PsA, two (9.1%) axial, and nine (40.9%) mixed; 5/22 (22.7%) patients were B27-positive. IC recurred in 2/22 (9%) patients over the follow-up period. Mean follow-up duration was 51 ± 23.2 months. Dactylitis was significantly more frequent in patients with IC compared to those without this feature (P = 0.032).

CONCLUSION

IC occurred in 9% of 242 patients with early PsA with no association with the clinical pattern and B27 positivity. This frequency is higher than previously reported.

Clinical features of ankylosing spondylitis associated with acute anterior uveitis in Chinese patients

AIM

To characterize the clinical features, diagnosis, treatment and prognosis of uveitis associated with ankylosing spondylitis (AS) in Chinese patients.

METHODS

Two hundred and three patients with uveitis associated with AS followed-up in the Third Military Medical University Daping Hospital between 2005 and 2010 were retrospectively evaluated in this study. Complete ophthalmological examinations were evaluated at baseline and during the follow-up period. The gender, age, follow-up time, mean frequency of uveitis onset, and accompanying eye examination findings, history, demographical parameters were reviewed. All the patients presented complete clinical and radiologic (sacroiliac, lumbar, dorsal and cervical spine, knee, ankle, shoulder, hip, elbow) evaluation. HLA-B27 typing was also searched.

RESULTS

There were 203 patients diagnosed with AS associated uveitis. All showed sacroiliac X-ray changes indicative of AS. There were 184 male and 19 female patients. The average age of patients was 35±12 (range 18-50). Mean follow-up period was 2.4 years (1-5 years). Acute anterior uveitis was the most common type of uveitis in both genders. 121 eyes presented unilateral involvement (55.2%), and 92 eyes presented bilateral involvement (45.3%) with onset alternately. 22 eyes occurred hypopyon, 16 eyes were found anterior vitreous cells, 7 eyes were noted reactive macular edema or exudation, 29 eyes presented posterior synechiae of iris, and 14 eyes presented cataract, 9 eyes presented secondary glaucoma, 2 eyes presented bend corneal degeneration and 1 eyes presented atrophy of eyeball. At the final visit, uveitis was well controlled in most patients.

CONCLUSION

AS associated with uveitis in Chinese patients mainly manifests as acute anterior uveitis. A combination of corticosteroids with other mydriasis agents is effective for most AS associated with uveitis patients. In general, the prognosis is good in these cases.

Prevalence of eye disease in Brazilian patients with psoriatic arthritis

OBJECTIVES

The aim of this study was to report the type and frequency of ocular manifestations in Brazilian psoriatic arthritis patients.

METHODS

We conducted a cross-sectional study in a Brazilian tertiary hospital. The test group included 40 patients who had psoriatic arthritis according to the Classification Criteria for Psoriatic Arthritis. A control group of 40 individuals was matched for age and gender. All of the patients underwent ophthalmic evaluation, which included best-corrected visual acuity, slit lamp and fundus examinations, and dry eye diagnostic tests (Schirmer I, tear breakup time and rose bengal). Demographic parameters were also evaluated.

RESULTS

The mean age of the patients was 53.9±13.1 years; the mean disease duration was 8±10.5 years. Most of the patients were women (60%), and the majority had polyarticular disease (57.5%). Several ocular abnormalities were found, including punctate keratitis, pinguecula, blepharitis, pterygium, cataract, glaucoma, uveitis, and retinal microvascular abnormalities. There were no significant differences in the rates of these abnormalities compared with the control group, however. The Keratoconjunctivitis sicca and dry eye diagnostic tests were more often positive in the patients with psoriatic arthritis than in the control group.

CONCLUSIONS

In this study, keratoconjunctivitis sicca was the most common ocular finding related to psoriatic arthritis. Therefore, we recommend early ophthalmologic evaluations for all psoriatic arthritis patients who complain of eye symptoms.

Demographic, clinical, laboratory and treatment characteristics of spondyloarthritis patients with and without acute anterior uveitis

CONTEXT AND OBJECTIVE

Acute anterior uveitis is a common extra-articular manifestation in spondyloarthritis patients. The aim of this study was to compare demographic, clinical, laboratory and treatment data among spondyloarthritis patients with and without acute anterior uveitis.

DESIGN AND SETTING

This was a cross-sectional analytical study at the Rheumatology Outpatient Clinic of the Evangelical University Hospital, Curitiba, Brazil.

METHODS

Spondyloarthritis patients with without acute anterior uveitis were compared regarding demographic data, spondyloarthritis subtype, peripheral arthritis, enthesitis, disease activity, functional index, physical examination, radiological involvement, HLA-B27 and treatment.

RESULTS

Presence of acute anterior uveitis was not found to have any relationship with functional index, degree of radiological involvement, peripheral arthritis or enthesitis. Acute anterior uveitis showed a negative association with skin manifestations (P = 0.04) and a trend towards higher disease activity (P = 0.06).

CONCLUSION

In the study sample, it could not be shown that AAU had any association with the functional and radiological prognoses. The patients with spondyloarthritis with and without acute anterior uveitis did not differ clinically except for a higher proportion of ankylosing spondylitis and smaller presence of skin involvement in those with uveitis.

TNF-α antagonists beyond approved indications: stories of success and prospects for the future

Tumour necrosis factor alpha (TNF-α) is a key molecule of the inflammatory response and data derived from studies in experimental animal models and humans suggest that TNF-α may be implicated in the pathogenesis of various autoimmune and non-infectious inflammatory conditions. Over the past decade pharmaceutical agents directed against TNF-α (infliximab, adalimumab and etanercept) have been widely and successfully employed for the management of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriasis, psoriatic arthritis, juvenile idiopathic arthritis and inflammatory bowel disease, whereas two novel anti-TNF-α agents, golimumab and certolimumab pegol, recently entered the market for the treatment of RA, AS, Crohn's disease and psoriasis. Encouraged by the positive results obtained from the use of TNF-α antagonists in terms of efficacy and safety and due to the increasingly accumulating evidence regarding the implication of TNF-α in the pathogenesis of numerous disorders, anti-TNF-α agents have been considered for the management of diseases other than the ones they were initially approved for. Although in the case of multiple sclerosis and chronic heart failure the outcome from the administration of TNF-α blockers had been less than favourable, in other cases of non-infectious inflammatory conditions the response to TNF-α inhibition had been fairly beneficial. More specifically, according to well-documented clinical trials, anti-TNF-α agents exhibited favourable results in Behçet's disease, non-infectious ocular inflammation, pyoderma gangrenosum and hidradenitis suppurativa. In this review we discuss the successful outcomes as well as the prospects for the future from the off-label use of TNF-α antagonists.

Clinical and demographic characteristics of patients with psoriatic arthritis in northern Israel

Disease patterns and manifestations may vary among different populations and change over time. The purpose of our study was to define the demographic, clinical, roentgenologic, and laboratory findings in a recent cohort of psoriatic arthritis patients followed up in rheumatology clinics in northern Israel. We conducted a cross-sectional study of 149 psoriatic arthritis patients. Demographic, clinical, laboratory, and radiological data, with emphasis on the pattern of arthritis, treatment regimens, and co-morbidities were obtained from patient interviews and rheumatology file reviews. The mean age of our patients was 58.2, with a female preponderance (57.3%). Skin involvement preceded the arthritis or was diagnosed simultaneously in 90.1% of cases. The most common joint involvement was an RA-like arthritis (49.7% of the patients) correlating positively with age, female gender, and disease duration. Dactylitis and nail involvement were observed in 33.6 and 36.2% of the patients, respectively. Radiographic bone erosions were noted in a third of the patients, correlating with DIP and RA-like arthritis patterns. Most patients were treated with methotrexate (73.8%) and a combination therapy (41.4%). An increased incidence of hypertension, hyperlipidemia, and diabetes mellitus was noted in our cohort compared to the general Israeli population. Our survey, the first of its kind conducted in Israel, noted a relative increase in the polyarticular manifestation of PsA and a decrease in spondyloarthropathy, compared to historic series, with more aggressive disease found in women above the age of sixty. These findings are in line with recent surveys.

Human leukocyte antigen-B27-associated uveitis: long-term follow-up and gender differences

PURPOSE

To evaluate clinical features and gender differences in human leukocyte antigen (HLA)-B27-associated acute anterior uveitis (AAU) in long-term follow-up.

DESIGN

Retrospective cohort study.

METHODS

The clinical records of 177 HLA-B27-positive patients (96 males [54%] and 81 females [46%]) who sought treatment for acute anterior uveitis (AAU) at the University Medical Center Utrecht between January 1995 and December 2005 were evaluated. All patients had a minimum follow-up of at least one year. The clinical data were analyzed at standardized intervals (one, five, and 10 years after the onset of uveitis).

RESULTS

Average age at onset of AAU was 36 years, with no differences between males and females. HLA-B27-associated systemic disease developed earlier in males than in females (31 vs 37 years; P=.021). Consequently, at onset of AAU, HLA-B27-associated systemic disease were more frequent in males than in females (25/75 [33%] males vs nine/54 [17%] females; P=.030); however over time, males and females were at equal risk of developing a HLA-B27-associated systemic disease. Bilateral uveitis developed more frequently in females (6/45 [13%] of males vs 11/35, [31%] of females; P=.05). In none of the patients did bilateral visual acuity of less than 0.5 develop after the follow-up of 10 years.

CONCLUSIONS

The long-term visual prognosis of HLA-B27-associated AAU was favorable, despite the frequent attacks of severe AAU. At the onset of AAU, the prevalence of HLA-B27-associated systemic disease was more frequent in males, but after the onset of uveitis, the risk of developing a HLA-B27-associated systemic disease is similar for both males and females.

Usefulness of human leucocyte antigen-B27 subtypes in predicting ankylosing spondylitis: Taiwan experience

BACKGROUND

Genetic factors are clearly attributed to the susceptibility of ankylosing spondylitis (AS). The human leucocyte antigen (HLA)-B27 proved to be the very useful marker for diagnosing AS. The aim of this study was to determine the prevalence of HLA-B27 subtypes in Taiwan and to investigate whether these subtypes may be of help in predicting the diagnosis of AS.

METHODS

A total of 314 patients with AS and a control group of 71 subjects positive for HLA-B27 detected by flow cytometry analysis were recruited for the study. HLA-B27 subtypes were confirmed by the polymerase chain reaction-sequence-specific primers and sequence-specific oligonucleotide probing.

RESULTS

Four B27 alleles were identified: B*2704, B*2705, B*2706 and B*2707. HLA-B*2704 was the predominant allele. There were significant differences in the distribution of HLA-B27 subtypes between patients with AS and controls. Five of them who were homozygous for the B*2704 allele were solely found in AS group but not in controls. Statistical analysis showed that B*2704 was positively associated with AS, which suggested an increased possibility of having AS. Other HLA-B27 subtypes showed no strong correlation with AS.

CONCLUSION

In the Taiwanese population, susceptibility to AS was determined by the presence of HLA-B*2704. Although B*2706 was reported to have a negative association with AS in Taiwanese, Thai and Chinese Singaporean populations, we report, in our study, two AS patients with B*2706 (0.6%). Disease heterogeneity suggests that other than genetic background, many pathogenic factors could be associated with AS. This may need to be investigated with a larger group of patients with AS and controls.

Frequency of HLA-B27 and its alleles in patients with Reiter syndrome: comparison with the frequency in other spondyloarthropathies and a healthy control population

This retrospective study analyzed the HLA-B 27 alleles in a group of 20 consecutive patients with the diagnosis of Reiter syndrome (RS) followed in a tertiary referral university hospital in Brazil, during the period 1990-2006, and compared the data with that observed in other patients with spondyloarthropathies followed at the same institution. Eight cases were associated to gastrointestinal infection, eight cases to previous urethritis, and four cases presented no established preceding infection. HLA-B 27 alleles were typed by polymerase chain reaction-amplified DNA hybridized with sequence-specific oligonucleotide probes (HLA-B 2,701 to HLA-B 2,721). They were compared to a group of 108 patients with ankylosing spondylitis (AS), 40 with undifferentiated spondyloarthropathy (uSpA) and 111 healthy controls. Among the 20 patients, 17 were HLA-B 27 positive (85%). Two HLA-B 27 alleles were observed: HLA-B 2,705 (65%) and HLA-B 2,702 (35%). In the other spondyloarthropathies, the observed alleles were HLA-B 2,705 (90% in AS and 92.5% in uSpA), HLA-B 2,702 (8% in AS and 5% in uSpA), HLA-B 2,704 (1% in AS and 2.5% in uSpA) and HLA-B 2,713 (1% in AS). Among the 111 healthy controls, 80% presented HLA-B 2,705, followed by HLA-B 2,702 in 10%, HLA-B 2,703 in 6%, HLA-B 2,707 in 3% and HLA-B 2,713 in 1%. Concluding, in the HLA-B 27 positive patients with RS in this study there was predominance of HLA-B 2,705 allele, in a lower frequency than that observed in patients with other spondyloarthropathies and healthy controls.

Immunogenetics of ocular inflammatory disease

Ocular inflammatory disease comprises of a diverse group of clinical entities that may result from autoimmune processes, infections, or both. While many individual ocular inflammatory diseases are quite rare, ocular inflammation is one of the more common causes of visual disability, including blindness, in the developed world. Better understanding of ocular inflammatory disease is an important step in designing more sophisticated therapies that may help prevent loss of visual function for these patients.